Initial Patient Health Assessment Form

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Transcription:

Initial Patient Health Assessment Form General Information: Patient Name:, Date: / /20 Patient s Address:. City:, State:, Zip Code: Home Phone #: - -, Work Phone #: - -, Cell #: - - E-mail address:, Date of Birth: / / Social Security #: - -. Sex: M, F, Patient Occupation:, Patient s Employer/School:. Patient s Employer/School address:. Patient s Employer/School Phone #: - - Health Insurance Plan:, Group #: Member ID #:, Other Health Insurance:, Group #: Member ID #:. *Name of Insured (if other than you):. Relation to Patient:, Date of Birth: / / Insured Social Security #: - -. Insured s Employer:. Who may we thank for referring you to the office for treatment?. Health Insurance Plan:, Group #: Member ID #:, Other Health Insurance:. In case of an Emergency, contact: Name: Relationship:, Home #: - -, Work #: - -, Cell #: - -, 1

Symptom/Condition History: 1) Please describe your current condition and how the problem began: 2) How long have you had this problem? 3) What caused your problem? (Check appropriate box below) or explain: Auto accident Work related accident Gradual Sudden other type of accident, please explain below: 4) How would you describe your pain? (Mark all that pertains to your pain) Sharp Soreness Throbbing Tingling Dull Stiffness Spasm Burning Ache Weakness Numbness Shooting 5) How would you rate the intensity of your pain right now? (Circle a number) 0 1 2 3 4 5 6 7 8 9 10 (No Pain) (Minimal) (Mild) (moderate) (severe) (unbearable) 6) How often is the pain present during your waking day? (Check appropriate box) 0% 7) Pain Scale: 0 is no pain & 10 is the worst possible pain, please circle the number below that indicates the amount of pain you are experiencing right now. 0 1 2 3 4 5 6 7 8 9 10 (No Pain) (Minimal) (Mild) (moderate) (severe) (unbearable) 8) Since your problem began, is your pain getting, Better, Worse, Staying the same. 9) What makes your problem better? Nothing Walking Standing Sitting Lying down Moving Rest Others: 10) What makes your problem worse? Others: 2

Symptom/Condition History Continued: 11) Are you currently taking any medications for this condition or any other conditions? Please name your condition(s), the medications name, the amount taken daily (mg), and how many times a day you take the medication (1/2/3etc ). 12) Do you take any vitamins, herbs, or nutritional supplements?, the product, the amount taken daily (mg), and how many times a day you take them (1/2/3etc ). 13) Were you previously treated for this condition?, No, if yes, in your own words please describe below which professional provider diagnosed your condition, and the outcome of the treatment. Please explain in detail: 14) What were the approximate dates of your treatments, the type of treatments, and your response to your treatments? 15) How physical is your activity at work? Mostly sitting Light manual Moderate manual Heavy manual 3

Symptom/Condition History Continued: 16) Do you exercise? No regular exercise 1-2 times/week 3-4 times/week 5-7 times/week Cardiovascular Stretching Weight Machine Free Weights Please explain: and/ or, Please explain: 17) What is your general stress level? No Stress Minimal Stress Moderate Stress Very Stressed 18) Is your problem affecting your ability to work or do other routine daily activities? No effect Have some restrictions but can function cannot work totally disabled On the Anatomical Diagram below Please mark with the letters below where you are experiencing pain or other symptoms right now. A = ACHE, B = BURNING, N = NUMBNESS, S = STABBING, P/N = PINS & NEEDLES (TINGLING), S/S = SHARP SHOOTING, W = WEEKNESS IN MUSCLES OTHERS: Right Left Left Right Front Back 4

Family History Please review the list below of diseases and conditions and Mark an X to indicate any current health conditions of a family member. Please leave the spaces blank that do not apply to any family member. If you where adopted please mark please leave the Family History blank. Conditions Back Conditions Neck Conditions Disc Problems back Neuritis Neuralgia Pinched nerve Scoliosis Epilepsy Osteoarthritis Rheumatoid Arthritis Bursitis Depression Stomach Conditions Constipation Headaches Migraine Headaches Asthma-Hay Fever Sinus Conditions Lung Conditions Emphysema COPD Heart Conditions By Pass Hypertension Kidney Conditions Liver Conditions Cancer Insomnia Diabetes Type I Diabetes Type II Father Mother Spouse Brother(s) Sister(s) Children(s) Age ( ) Age ( ) Age ( ) Age ( ) Age ( ) Age ( ) Age ( ) Age ( ) Age ( ) If the above parents or siblings were deceased, how old were they, and what condition did they pass away from? 5

Past or Present Symptoms, Conditions or Habits: Please check the box indicating whether this applies to past or present. Symptoms/Conditions: Past Present Diagnosis Date *Rheumatoid arthritis Osteoarthritis Ankylosing spondylitis Bone fractures: Malignancy of the spine Infection of the bones or joints Myelopathy Cauda Equina syndrome Carotid artery problems Aneurysm *Instability of joints Benign tumors of the spine Osteoporosis Bleeding disorders Nerve problems Multiple Sclerosis Anticoagulants/blood thinning therapy *Dizziness Drop Attacks Double vision Difficulty speaking Difficulty swallowing Nausea Numbness Nystagmus Neck pain Jaw pain TMJ/TMD Headaches: Type: Fainting spells High blood pressure Stroke Transient ischemic attacks *Shoulder pain Arm/ and pain Neck Pain Upper back pain Lower back pain Hip pain Knee pain Ankle/ Foot pain / / 6

Past or Present Symptoms, Conditions or Habits Continued: Symptoms/Conditions: Past Present Diagnosis Date Fatigue Respiratory condition Digestive problems Kidney problems Menstrual problems Sinus/ allergy/ asthma conditions Weight Gain/ oss lb Cancer Type: Skin condition Diabetes: I / Prostate problems *Tobacco use: # Packs per day brand of cigarettes:, Onset of smoking: / /, how many years have you been smoking?. Alcohol use: # of drinks per day, type of Alcohol: & Other liquor:. Caffeine use: # of Cups per day. Pregnancy: * Pregnancy Vaginal Delivery Dates: / /, / /, / / * Pregnancy C-Section Delivery Dates: / /, / /, / / Epidural Injections: how many, and dates: / /, / /, *Surgery Dates: / /, / /, / /, / /, Surgery: Please explain what type of surgery you had in the past: *Is there any other condition or information that you feel is important to you and would like Dr. Rooney to be aware of and if so, please explain:? Patient s Signature:, Date: / /20 Guardian Signature:, Date: / /20 (If the patient is a minor) 7

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